Every Republican contender for the presidency in the primaries is going to have to swear that they will repeal Obamacare. Unfortunately, the man (and it will be a man) who ends up with the nomination, will have to have a replacement plan. That was
particularly tricky for Mitt Romney who created the precursor to Obamacare, Romneycare. So this cycle's nominee is going to have to come to the table with something different, something conservative, something that everyone won't hate. The problem for him is that something just doesn't exist.
After Obamacare repeal, the stuff that people like is going to have to be kept—no more preexisting conditions being the most critical provision. Keeping that in place while jettisoning everything else—and keeping insurers on board if they don't have a captive consumer base—has been too impossible for Republicans to figure out yet. So they've been kicking around a handful of ideas—selling insurance across state lines, catastrophic high-risk pools, block-granting Medicaid—which are ideologically pleasing, but practically disastrous. The "brains" in conservative healthcare policy wonkdom are Avik Roy, a senior fellow at the Manhattan Institute and Douglas Holtz-Eakin, former director of the Congressional Budget Office. They're pushing three "big" ideas: change the tax treatment of health insurance so that employer contributions are taxed; create some kind of safety net to replace Medicaid expansion and Obamacare subsidies; do something for small business. And in each of them there's jeopardy for Republicans.
Here is one instructive episode. Last year, Republican Sens. Richard Burr, Orrin Hatch, and Tom Coburn produced a comprehensive health care plan. It would have initially capped the employer exclusion, as it's called, at 65 percent of the "average (health) plan's costs."
That would have meant a huge tax increase for a lot of Americans—hundreds of billions of dollars combined, by some estimates. That attracted critical press coverage, which led to the senators quietly revising their plan to cap the exclusion at the average cost of an "expensive high-option plan," significantly reducing the impact—and therefore political risk. But that is indicative of the tricky terrain that the 2016 candidates will be navigating.
Just as potentially unpopular—though the Supreme Court might take care of this for them—is doing away with the subsidies that make insurance affordable for so many under Obamacare. So far, the brains have come up with "the possibility of continuing some kind of tax credit to help people buy private insurance." Which is what we have now under Obamacare. In fact, "[t]hat's where the action is," Roy says, recreating what's already in Obamacare, but different. The same goes for their small business plan ideas: "One is letting small businesses pool together and shop for insurance as a unit, not unlike the Obamacare marketplaces. Another is giving them some kind of special tax credit."
Which is not so much unlike the Romney replacement plan for Obamacare—basically Obamacare but with a big red GOP stamp on it, and a lot more pain for poor people. Because that's the most important thing for Republicans. After all, you only want the most "deserving"—those who can pay for it—to get the best health care.